VITOSS CANISTER 15CC 1-4MM
|
Facility
|
IP
|
$7,107.00
|
|
Service Code
|
HCPCS C9359
|
Hospital Charge Code |
27000053
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$923.91 |
Max. Negotiated Rate |
$6,822.72 |
Rate for Payer: Aetna Commercial |
$5,472.39
|
Rate for Payer: Anthem POS/PPO/Traditional |
$5,543.46
|
Rate for Payer: Cash Price |
$3,553.50
|
Rate for Payer: Cigna Commercial |
$5,898.81
|
Rate for Payer: First Health Commercial |
$6,751.65
|
Rate for Payer: Humana Commercial |
$6,040.95
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.74
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.97
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$2,132.10
|
Rate for Payer: Ohio Health Choice Commercial |
$6,254.16
|
Rate for Payer: Ohio Health Group HMO |
$5,330.25
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,421.40
|
Rate for Payer: Ohio Health Group PPO No Differential |
$923.91
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,203.17
|
Rate for Payer: PHCS Commercial |
$6,822.72
|
Rate for Payer: United Healthcare All Payer |
$6,254.16
|
|
VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;
|
Facility
|
OP
|
$4,922.33
|
|
Service Code
|
CPT 67036
|
Hospital Revenue Code
|
360
|
Min. Negotiated Rate |
$3,515.95 |
Max. Negotiated Rate |
$4,922.33 |
Rate for Payer: Anthem Medicare Advantage/PPO |
$3,515.95
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,922.33
|
Rate for Payer: CareSource Just4Me Medicare |
$4,746.53
|
Rate for Payer: Humana Medicare Advantage |
$3,515.95
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$4,219.14
|
|
VIVACTIL 10MG TABLET
|
Facility
|
OP
|
$12.78
|
|
Service Code
|
NDC 54021125
|
Hospital Charge Code |
25001695
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$1.66 |
Max. Negotiated Rate |
$12.27 |
Rate for Payer: Aetna Commercial |
$9.84
|
Rate for Payer: Anthem Medicaid |
$4.40
|
Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
Rate for Payer: Cash Price |
$6.39
|
Rate for Payer: Cigna Commercial |
$10.61
|
Rate for Payer: First Health Commercial |
$12.14
|
Rate for Payer: Humana Commercial |
$10.86
|
Rate for Payer: Humana KY Medicaid |
$4.40
|
Rate for Payer: Kentucky WC Medicaid |
$4.44
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
Rate for Payer: Molina Healthcare Medicaid |
$4.48
|
Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
Rate for Payer: Ohio Health Group HMO |
$9.58
|
Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
Rate for Payer: Ohio Health Group PPO No Differential |
$1.66
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.96
|
Rate for Payer: PHCS Commercial |
$12.27
|
Rate for Payer: United Healthcare All Payer |
$11.25
|
|
VIVACTIL 10MG TABLET
|
Facility
|
IP
|
$12.78
|
|
Service Code
|
NDC 54021125
|
Hospital Charge Code |
25001695
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$1.66 |
Max. Negotiated Rate |
$12.27 |
Rate for Payer: Humana Commercial |
$10.86
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
Rate for Payer: Ohio Health Group HMO |
$9.58
|
Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
Rate for Payer: Ohio Health Group PPO No Differential |
$1.66
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.96
|
Rate for Payer: PHCS Commercial |
$12.27
|
Rate for Payer: United Healthcare All Payer |
$11.25
|
Rate for Payer: Aetna Commercial |
$9.84
|
Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
Rate for Payer: Cash Price |
$6.39
|
Rate for Payer: Cigna Commercial |
$10.61
|
Rate for Payer: First Health Commercial |
$12.14
|
|
VIVACTIL 5MG TABLET
|
Facility
|
IP
|
$12.78
|
|
Service Code
|
NDC 54021025
|
Hospital Charge Code |
25001696
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$1.66 |
Max. Negotiated Rate |
$12.27 |
Rate for Payer: Aetna Commercial |
$9.84
|
Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
Rate for Payer: Cash Price |
$6.39
|
Rate for Payer: Cigna Commercial |
$10.61
|
Rate for Payer: First Health Commercial |
$12.14
|
Rate for Payer: Humana Commercial |
$10.86
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
Rate for Payer: Ohio Health Group HMO |
$9.58
|
Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
Rate for Payer: Ohio Health Group PPO No Differential |
$1.66
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.96
|
Rate for Payer: PHCS Commercial |
$12.27
|
Rate for Payer: United Healthcare All Payer |
$11.25
|
|
VIVACTIL 5MG TABLET
|
Facility
|
OP
|
$12.78
|
|
Service Code
|
NDC 54021025
|
Hospital Charge Code |
25001696
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$1.66 |
Max. Negotiated Rate |
$12.27 |
Rate for Payer: Aetna Commercial |
$9.84
|
Rate for Payer: Anthem Medicaid |
$4.40
|
Rate for Payer: Anthem POS/PPO/Traditional |
$9.97
|
Rate for Payer: Cash Price |
$6.39
|
Rate for Payer: Cigna Commercial |
$10.61
|
Rate for Payer: First Health Commercial |
$12.14
|
Rate for Payer: Humana Commercial |
$10.86
|
Rate for Payer: Humana KY Medicaid |
$4.40
|
Rate for Payer: Kentucky WC Medicaid |
$4.44
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$10.48
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.43
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$3.83
|
Rate for Payer: Molina Healthcare Medicaid |
$4.48
|
Rate for Payer: Ohio Health Choice Commercial |
$11.25
|
Rate for Payer: Ohio Health Group HMO |
$9.58
|
Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
Rate for Payer: Ohio Health Group PPO No Differential |
$1.66
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.96
|
Rate for Payer: PHCS Commercial |
$12.27
|
Rate for Payer: United Healthcare All Payer |
$11.25
|
|
VIVARIN (CAFFEINE)200MG TABLET
|
Facility
|
IP
|
$4.34
|
|
Service Code
|
NDC 46017001816
|
Hospital Charge Code |
25001697
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.56 |
Max. Negotiated Rate |
$4.17 |
Rate for Payer: Aetna Commercial |
$3.34
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
Rate for Payer: Cash Price |
$2.17
|
Rate for Payer: Cigna Commercial |
$3.60
|
Rate for Payer: First Health Commercial |
$4.12
|
Rate for Payer: Humana Commercial |
$3.69
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
Rate for Payer: Ohio Health Group HMO |
$3.26
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
Rate for Payer: PHCS Commercial |
$4.17
|
Rate for Payer: United Healthcare All Payer |
$3.82
|
|
VIVARIN (CAFFEINE)200MG TABLET
|
Facility
|
OP
|
$4.34
|
|
Service Code
|
NDC 46017001816
|
Hospital Charge Code |
25001697
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$0.56 |
Max. Negotiated Rate |
$4.17 |
Rate for Payer: Aetna Commercial |
$3.34
|
Rate for Payer: Anthem Medicaid |
$1.49
|
Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
Rate for Payer: Cash Price |
$2.17
|
Rate for Payer: Cigna Commercial |
$3.60
|
Rate for Payer: First Health Commercial |
$4.12
|
Rate for Payer: Humana Commercial |
$3.69
|
Rate for Payer: Humana KY Medicaid |
$1.49
|
Rate for Payer: Kentucky WC Medicaid |
$1.51
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
Rate for Payer: Ohio Health Group HMO |
$3.26
|
Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
Rate for Payer: PHCS Commercial |
$4.17
|
Rate for Payer: United Healthcare All Payer |
$3.82
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
IP
|
$21.97
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
63600146
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.86 |
Max. Negotiated Rate |
$21.09 |
Rate for Payer: Aetna Commercial |
$16.92
|
Rate for Payer: Anthem POS/PPO/Traditional |
$17.14
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cigna Commercial |
$18.24
|
Rate for Payer: First Health Commercial |
$20.87
|
Rate for Payer: Humana Commercial |
$18.67
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$18.02
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.21
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$6.59
|
Rate for Payer: Ohio Health Choice Commercial |
$19.33
|
Rate for Payer: Ohio Health Group HMO |
$16.48
|
Rate for Payer: Ohio Health Group PPO Differential |
$4.39
|
Rate for Payer: Ohio Health Group PPO No Differential |
$2.86
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.81
|
Rate for Payer: PHCS Commercial |
$21.09
|
Rate for Payer: United Healthcare All Payer |
$19.33
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
OP
|
$8,944.05
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
25004089
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$3.96 |
Max. Negotiated Rate |
$8,586.29 |
Rate for Payer: Aetna Commercial |
$6,886.92
|
Rate for Payer: Anthem Medicaid |
$3,075.86
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$3.96
|
Rate for Payer: Anthem POS/PPO/Traditional |
$6,976.36
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.54
|
Rate for Payer: CareSource Just4Me Medicare |
$5.34
|
Rate for Payer: Cash Price |
$4,472.02
|
Rate for Payer: Cash Price |
$4,472.02
|
Rate for Payer: Cigna Commercial |
$7,423.56
|
Rate for Payer: First Health Commercial |
$8,496.85
|
Rate for Payer: Humana Commercial |
$7,602.44
|
Rate for Payer: Humana KY Medicaid |
$3,075.86
|
Rate for Payer: Humana Medicare Advantage |
$3.96
|
Rate for Payer: Kentucky WC Medicaid |
$3,107.16
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$7,334.12
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,600.71
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$4.75
|
Rate for Payer: Molina Healthcare Medicaid |
$3,137.57
|
Rate for Payer: Ohio Health Choice Commercial |
$7,870.76
|
Rate for Payer: Ohio Health Group HMO |
$6,708.04
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,788.81
|
Rate for Payer: Ohio Health Group PPO No Differential |
$1,162.73
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,772.66
|
Rate for Payer: PHCS Commercial |
$8,586.29
|
Rate for Payer: United Healthcare All Payer |
$7,870.76
|
|
VIVITROL 1mg (380mg vial)
|
Professional
|
Both
|
$21.97
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
63600146
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.54 |
Max. Negotiated Rate |
$21.97 |
Rate for Payer: Aetna Commercial |
$4.83
|
Rate for Payer: Buckeye Medicare Advantage |
$21.97
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Healthspan PPO |
$2.54
|
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4.86
|
Rate for Payer: Multiplan PHCS |
$13.18
|
Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15.38
|
Rate for Payer: UHCCP Medicaid |
$7.69
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
OP
|
$21.97
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
636T0146
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.86 |
Max. Negotiated Rate |
$21.09 |
Rate for Payer: Aetna Commercial |
$16.92
|
Rate for Payer: Anthem Medicaid |
$7.56
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$3.96
|
Rate for Payer: Anthem POS/PPO/Traditional |
$17.14
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.54
|
Rate for Payer: CareSource Just4Me Medicare |
$5.34
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cigna Commercial |
$18.24
|
Rate for Payer: First Health Commercial |
$20.87
|
Rate for Payer: Humana Commercial |
$18.67
|
Rate for Payer: Humana KY Medicaid |
$7.56
|
Rate for Payer: Humana Medicare Advantage |
$3.96
|
Rate for Payer: Kentucky WC Medicaid |
$7.63
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$18.02
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.21
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$4.75
|
Rate for Payer: Molina Healthcare Medicaid |
$7.71
|
Rate for Payer: Ohio Health Choice Commercial |
$19.33
|
Rate for Payer: Ohio Health Group HMO |
$16.48
|
Rate for Payer: Ohio Health Group PPO Differential |
$4.39
|
Rate for Payer: Ohio Health Group PPO No Differential |
$2.86
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.81
|
Rate for Payer: PHCS Commercial |
$21.09
|
Rate for Payer: United Healthcare All Payer |
$19.33
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
OP
|
$21.97
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
63600146
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.86 |
Max. Negotiated Rate |
$21.09 |
Rate for Payer: Aetna Commercial |
$16.92
|
Rate for Payer: Anthem Medicaid |
$7.56
|
Rate for Payer: Anthem Medicare Advantage/PPO |
$3.96
|
Rate for Payer: Anthem POS/PPO/Traditional |
$17.14
|
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.54
|
Rate for Payer: CareSource Just4Me Medicare |
$5.34
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cigna Commercial |
$18.24
|
Rate for Payer: First Health Commercial |
$20.87
|
Rate for Payer: Humana Commercial |
$18.67
|
Rate for Payer: Humana KY Medicaid |
$7.56
|
Rate for Payer: Humana Medicare Advantage |
$3.96
|
Rate for Payer: Kentucky WC Medicaid |
$7.63
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$18.02
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.21
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$4.75
|
Rate for Payer: Molina Healthcare Medicaid |
$7.71
|
Rate for Payer: Ohio Health Choice Commercial |
$19.33
|
Rate for Payer: Ohio Health Group HMO |
$16.48
|
Rate for Payer: Ohio Health Group PPO Differential |
$4.39
|
Rate for Payer: Ohio Health Group PPO No Differential |
$2.86
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.81
|
Rate for Payer: PHCS Commercial |
$21.09
|
Rate for Payer: United Healthcare All Payer |
$19.33
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
IP
|
$8,944.05
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
25004089
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$1,162.73 |
Max. Negotiated Rate |
$8,586.29 |
Rate for Payer: Aetna Commercial |
$6,886.92
|
Rate for Payer: Anthem POS/PPO/Traditional |
$6,976.36
|
Rate for Payer: Cash Price |
$4,472.02
|
Rate for Payer: Cigna Commercial |
$7,423.56
|
Rate for Payer: First Health Commercial |
$8,496.85
|
Rate for Payer: Humana Commercial |
$7,602.44
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$7,334.12
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,600.71
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$2,683.22
|
Rate for Payer: Ohio Health Choice Commercial |
$7,870.76
|
Rate for Payer: Ohio Health Group HMO |
$6,708.04
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,788.81
|
Rate for Payer: Ohio Health Group PPO No Differential |
$1,162.73
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,772.66
|
Rate for Payer: PHCS Commercial |
$8,586.29
|
Rate for Payer: United Healthcare All Payer |
$7,870.76
|
|
VIVITROL 1mg (380mg vial)
|
Facility
|
IP
|
$21.97
|
|
Service Code
|
HCPCS J2315
|
Hospital Charge Code |
636T0146
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2.86 |
Max. Negotiated Rate |
$21.09 |
Rate for Payer: Aetna Commercial |
$16.92
|
Rate for Payer: Anthem POS/PPO/Traditional |
$17.14
|
Rate for Payer: Cash Price |
$10.98
|
Rate for Payer: Cigna Commercial |
$18.24
|
Rate for Payer: First Health Commercial |
$20.87
|
Rate for Payer: Humana Commercial |
$18.67
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$18.02
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.21
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$6.59
|
Rate for Payer: Ohio Health Choice Commercial |
$19.33
|
Rate for Payer: Ohio Health Group HMO |
$16.48
|
Rate for Payer: Ohio Health Group PPO Differential |
$4.39
|
Rate for Payer: Ohio Health Group PPO No Differential |
$2.86
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.81
|
Rate for Payer: PHCS Commercial |
$21.09
|
Rate for Payer: United Healthcare All Payer |
$19.33
|
|
VIVITY LENS DFT315+14.0
|
Facility
|
IP
|
$5,682.50
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$738.72 |
Max. Negotiated Rate |
$5,455.20 |
Rate for Payer: Aetna Commercial |
$4,375.52
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
Rate for Payer: Cash Price |
$2,841.25
|
Rate for Payer: Cigna Commercial |
$4,716.48
|
Rate for Payer: First Health Commercial |
$5,398.38
|
Rate for Payer: Humana Commercial |
$4,830.12
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
Rate for Payer: PHCS Commercial |
$5,455.20
|
Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
VIVITY LENS DFT315+14.0
|
Facility
|
OP
|
$5,682.50
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$738.72 |
Max. Negotiated Rate |
$5,455.20 |
Rate for Payer: Aetna Commercial |
$4,375.52
|
Rate for Payer: Anthem Medicaid |
$1,954.21
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
Rate for Payer: Cash Price |
$2,841.25
|
Rate for Payer: Cigna Commercial |
$4,716.48
|
Rate for Payer: First Health Commercial |
$5,398.38
|
Rate for Payer: Humana Commercial |
$4,830.12
|
Rate for Payer: Humana KY Medicaid |
$1,954.21
|
Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
Rate for Payer: PHCS Commercial |
$5,455.20
|
Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
VIVITY LENS DFT315*20.0
|
Facility
|
IP
|
$5,525.00
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$718.25 |
Max. Negotiated Rate |
$5,304.00 |
Rate for Payer: Aetna Commercial |
$4,254.25
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
Rate for Payer: Cash Price |
$2,762.50
|
Rate for Payer: Cigna Commercial |
$4,585.75
|
Rate for Payer: First Health Commercial |
$5,248.75
|
Rate for Payer: Humana Commercial |
$4,696.25
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
Rate for Payer: PHCS Commercial |
$5,304.00
|
Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
VIVITY LENS DFT315*20.0
|
Facility
|
OP
|
$5,525.00
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$718.25 |
Max. Negotiated Rate |
$5,304.00 |
Rate for Payer: Aetna Commercial |
$4,254.25
|
Rate for Payer: Anthem Medicaid |
$1,900.05
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
Rate for Payer: Cash Price |
$2,762.50
|
Rate for Payer: Cigna Commercial |
$4,585.75
|
Rate for Payer: First Health Commercial |
$5,248.75
|
Rate for Payer: Humana Commercial |
$4,696.25
|
Rate for Payer: Humana KY Medicaid |
$1,900.05
|
Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
Rate for Payer: PHCS Commercial |
$5,304.00
|
Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
VIVITY LENS DFT315*20.5
|
Facility
|
IP
|
$5,682.50
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$738.72 |
Max. Negotiated Rate |
$5,455.20 |
Rate for Payer: Aetna Commercial |
$4,375.52
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
Rate for Payer: Cash Price |
$2,841.25
|
Rate for Payer: Cigna Commercial |
$4,716.48
|
Rate for Payer: First Health Commercial |
$5,398.38
|
Rate for Payer: Humana Commercial |
$4,830.12
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
Rate for Payer: PHCS Commercial |
$5,455.20
|
Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
VIVITY LENS DFT315*20.5
|
Facility
|
OP
|
$5,682.50
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$738.72 |
Max. Negotiated Rate |
$5,455.20 |
Rate for Payer: Aetna Commercial |
$4,375.52
|
Rate for Payer: Anthem Medicaid |
$1,954.21
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
Rate for Payer: Cash Price |
$2,841.25
|
Rate for Payer: Cigna Commercial |
$4,716.48
|
Rate for Payer: First Health Commercial |
$5,398.38
|
Rate for Payer: Humana Commercial |
$4,830.12
|
Rate for Payer: Humana KY Medicaid |
$1,954.21
|
Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
Rate for Payer: PHCS Commercial |
$5,455.20
|
Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
VIVITY LENS DFT315*22.0
|
Facility
|
IP
|
$5,682.50
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$738.72 |
Max. Negotiated Rate |
$5,455.20 |
Rate for Payer: Aetna Commercial |
$4,375.52
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
Rate for Payer: Cash Price |
$2,841.25
|
Rate for Payer: Cigna Commercial |
$4,716.48
|
Rate for Payer: First Health Commercial |
$5,398.38
|
Rate for Payer: Humana Commercial |
$4,830.12
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
Rate for Payer: PHCS Commercial |
$5,455.20
|
Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
VIVITY LENS DFT315*22.0
|
Facility
|
OP
|
$5,682.50
|
|
Service Code
|
HCPCS V2788
|
Hospital Charge Code |
27000231
|
Hospital Revenue Code
|
276
|
Min. Negotiated Rate |
$738.72 |
Max. Negotiated Rate |
$5,455.20 |
Rate for Payer: Aetna Commercial |
$4,375.52
|
Rate for Payer: Anthem Medicaid |
$1,954.21
|
Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
Rate for Payer: Cash Price |
$2,841.25
|
Rate for Payer: Cigna Commercial |
$4,716.48
|
Rate for Payer: First Health Commercial |
$5,398.38
|
Rate for Payer: Humana Commercial |
$4,830.12
|
Rate for Payer: Humana KY Medicaid |
$1,954.21
|
Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
Rate for Payer: PHCS Commercial |
$5,455.20
|
Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
VIVONEX RTF LIQUID 1000 ML
|
Facility
|
IP
|
$95.92
|
|
Service Code
|
HCPCS B4153
|
Hospital Charge Code |
25001807
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$12.47 |
Max. Negotiated Rate |
$92.08 |
Rate for Payer: Aetna Commercial |
$73.86
|
Rate for Payer: Anthem POS/PPO/Traditional |
$74.82
|
Rate for Payer: Cash Price |
$47.96
|
Rate for Payer: Cigna Commercial |
$79.61
|
Rate for Payer: First Health Commercial |
$91.12
|
Rate for Payer: Humana Commercial |
$81.53
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$78.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.79
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$28.78
|
Rate for Payer: Ohio Health Choice Commercial |
$84.41
|
Rate for Payer: Ohio Health Group HMO |
$71.94
|
Rate for Payer: Ohio Health Group PPO Differential |
$19.18
|
Rate for Payer: Ohio Health Group PPO No Differential |
$12.47
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.74
|
Rate for Payer: PHCS Commercial |
$92.08
|
Rate for Payer: United Healthcare All Payer |
$84.41
|
|
VIVONEX RTF LIQUID 1000 ML
|
Facility
|
OP
|
$95.92
|
|
Service Code
|
HCPCS B4153
|
Hospital Charge Code |
25001807
|
Hospital Revenue Code
|
637
|
Min. Negotiated Rate |
$12.47 |
Max. Negotiated Rate |
$92.08 |
Rate for Payer: Aetna Commercial |
$73.86
|
Rate for Payer: Anthem Medicaid |
$32.99
|
Rate for Payer: Anthem POS/PPO/Traditional |
$74.82
|
Rate for Payer: Cash Price |
$47.96
|
Rate for Payer: Cigna Commercial |
$79.61
|
Rate for Payer: First Health Commercial |
$91.12
|
Rate for Payer: Humana Commercial |
$81.53
|
Rate for Payer: Humana KY Medicaid |
$32.99
|
Rate for Payer: Kentucky WC Medicaid |
$33.32
|
Rate for Payer: Medical Mutual Of Ohio HMO |
$78.65
|
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.79
|
Rate for Payer: Molina Healthcare Benefit Exchange |
$28.78
|
Rate for Payer: Molina Healthcare Medicaid |
$33.65
|
Rate for Payer: Ohio Health Choice Commercial |
$84.41
|
Rate for Payer: Ohio Health Group HMO |
$71.94
|
Rate for Payer: Ohio Health Group PPO Differential |
$19.18
|
Rate for Payer: Ohio Health Group PPO No Differential |
$12.47
|
Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.74
|
Rate for Payer: PHCS Commercial |
$92.08
|
Rate for Payer: United Healthcare All Payer |
$84.41
|
|